Tuesday, January 28, 2014

Prostate cancer is the most common form of cancer in men.
While some types are life-threatening others are not.Recently the media have been reporting on serious
concerns that have surfaced about men with the benign forms of the disease undergoing
unnecessary radical treatment. PSA
screening has been receiving most of the blame, but the real problem is over
reliance on random needle biopsies performed by an aggressive medical community
made up of surgeons.Significance of an Elevated
PSA

An elevated PSA can occur as a result of any physical
alteration of the environment in the prostate-- recent sexual activity, infection,
cancer, and gland enlargement (BPH). A modest elevation of PSA is medically nonspecific. As one man explained, “Think
of the Check Engine light on the
dashboard of your car. It’s significant if it is ON, but further specifics need
to be determined before taking any action.”Time for a Random Biopsy?PSA elevation typically triggers an immediate 12-core
random biopsy. Presently, over a million men are undergoing biopsy every year
at a cost of billions of dollars. Unfortunately, low grade prostate cancer is so
prevalent in the general male population that a random biopsy will find
prostate cancer 20% of the time, even
when PSA is normal. Obviously a great preponderance of all this “cancer”
must be harmless. After all, historical death rates from prostate cancer before
1987, when PSA screening first became available, were only 3%.Damn the Possible Side
Effects, Treat it AnywayCancer is a frightening word. To many, it portends death.
Therefore it’s hardly surprising that both doctors and patients swing into immediate
action when the biopsy shows CANCER. Amending and tempering words such as “low
grade” or “microscopic” seem to produce no soothing affect whatsoever on the
instinctual fears generated by this venomous diagnosis.Despite the universal agreement of hundreds
of prostate experts at a consensus conference back in 2007 which concluded that
low-grade prostate cancer can be safely monitored, 85% of all men diagnosed
still throw caution to the wind and get treatment anyway.Imaging is “Blind” to
Small Low-Grade CancersBack when doctors regarded all types of prostate cancer as
universally dangerous, prostate imaging, which is prone to miss small,
low-grade lesions, was deemed inadequate. However, with our modern perspective,
knowing that only larger, higher-grade lesions are clinically relevant, imaging
makes perfect sense. There are two types of prostate imaging: High-resolution
Color Doppler Ultrasound, which is the subject of this blog, and
multiparametric 3-Tesla MRI which was the subject of my last blog.Color Doppler Ultrasound
ImagingIt’s no longer appropriate to needle the prostate
multiple times with the outdated belief that it’s essential to diagnose every
tiny prostate cancer.Practically
speaking, only prostate cancers large enough to be “seen” (with imaging) need
to be considered. Color Doppler Ultrasound scanning of the prostate is
performed by a physician in the doctor’s office. It is actually two scans in
one: Standard “Grey Scale” imaging and Color Doppler imaging to detect areas of
increased blood flow. First, ultrasound enables
accurate measurement of the gland size. Second, from a cancer point of view, imaging
with Color Doppler has three possible outcomes:

A)Completely clear

B)An overtly suspicious lesion is
detected

C)Ambiguous lesion(s) are detected

Targeted Rather than
Random BiopsiesWhen an overtly suspicious lesion is detected, a targeted biopsy (a limited number of
cores aimed directly at the lesion) is typically recommended. Lesions that are
biopsy-negative or show low-grade cancer are simply monitored.When high-grade disease is diagnosed, a
process of further staging followed by pertinent counseling about the different
treatment options is initiated.When to Biopsy Ambiguous
LesionsExpert judgment, with appropriate attention to the
individual patient characteristics, comes into play during a discussion between
patient and doctor about whether or not to do a targeted biopsy. Color Doppler
“sees” all sorts of things including scar tissue, areas of active prostatitis,
and nodular areas from BPH. A follow-up scan in six months to see if a lesion
shows further growth may be preferred to immediate biopsy.Lesion characteristics that raise greatest
concern tend to be located in the peripheral zone of the prostate, and include
lesions over a centimeter, lesions that bulge the prostate capsule and lesions
that have increased blood flow.Targeted
biopsy is advised more frequently in men who are younger, are more anxious
about missing cancer, and in men with PSA levels higher than they “should be” relative
to the size of their prostate.“Cross Checking” Ambiguous
Lesions with Multiparametric MRIColor Doppler Ultrasound and Multiparametric MRI (MP-MRI)
are complementary. In our experience the imaging findings match. However in a
minority of cases one imaging modality will illuminate a specific lesion
substantially more clearly. Therefore, in ambiguous cases, a combination of both
modalities increases confidence that high-grade cancer isn’t being overlooked. Doing
a second imaging procedure with MP-MRI is often preferable to doing an immediate
biopsy. If subsequently a targeted
biopsy is deemed necessary, the additional imaging information obtained from
MP-MRI may further increase the accuracy of the targeted biopsy.Color Doppler for Monitoring
Low-Grade CancerThese days’ experts advise men with low-grade prostate
cancer to forgo surgery or radiation and monitor their condition with Active Surveillance. The most common protocol used presently is regular PSA testing and periodic random biopsy. However,
multiple random biopsies are associated with discomfort and progressive risk of
serious infections and impotence. Sequential
monitoring of small lesions with Color Doppler to determine if they are growing
or stable is a far more logical approach than subjecting men to repeated
biopsies.Final ThoughtsMen with elevated PSA, who initially undergo a Color
Doppler, rather than random biopsy, are often spared biopsy altogether if their
scan is clear. Men who do require biopsy
will need far fewer cores taken because the biopsy is targeted to a specific
lesion within the gland. Men on Active Surveillance and men who have undergone
previous treatment with surgery, radiation, cryotherapy, HIFU or hormone
blockade are also candidates for Color Doppler Ultrasound to determine how well
they are responding to treatment.

Tuesday, January 21, 2014

BY RALPH BLUMAt
times, over these past decades, I have heard myself say, almost flippantly,
about the chronic form of prostate cancer that I, and most men with the disease
are dealing with, “Don’t worry—we’re going to die with it, not from it.” But in
the meantime?

I
almost had a bad fall last night. Barely recovered in time. I notice I am
increasingly wobbly. Unsteady. I lose my balance and barely recover to avoid
what might have been a serious fall. Suddenly the world is full of sharp edges
and uneven paths. What to do?

I know
the rules about exercise. But my body, heading for 82, is noticeably less
trustworthy than it was even a year ago. And because my knees and arms are not
capable of their former range of exercise (stationary bike, yes, walking and
treadmill, no) I can feel the constant ache and low-grade pain as my muscles
proceed to atrophy. And while I know there is “armchair yoga,” it isn’t that
easy to find a class, and I am less than enthusiastic to try it, so for now I
am yoga-less. What to do?

My
moaning is muffled. It could be so much worse! has become one of
my mantras, almost a prayer of thanks. I have one old friend, Jack, whose
pacemaker, following a stroke, has helped his heart outlive his brain. His
loving wife and friend of 43 years, Muriel, is still his aide and comforter,
helping him to the toilet, changing his diaper, getting him back comfortably
onto the couch, but, but . . .

Anton Chekhov, who died of tuberculosis in 1904, wrote:
“Whenever there is someone in a family who has long been ill, and hopelessly
ill, there come painful moments when all timidly, secretly, at the bottom of
their hearts, long for his death.” The truth is, secretly, and at the bottom of
her heart, Muriel would hope for that pacemaker in Jack’s chest to fail.

Which brings me to the troubling issue of American
Medical Overdoing. All the advances are functioning to keep Jack functioning.
Why? Because they can. Because someone is making money off stents, pacemakers,
airportdefibrillators, 911 emergency
assistance, insurance that pays for hugely expensive specialists. I can only
tell you that Muriel, who has seen too many close friends losing control of
their lives and slowly dying, keeps a copy of the Hemlock Society’s Final
Exit, underlined in red, on her desk.

The problem is—and it’s the result of medical
advances—the number of us who survive health crises that previously would have
killed us, is growing rapidly. The eldest of us are the nation’s most rapidly
growing age group. And, God help us, nearly one third of all Americans over 85 have some degree of dementia. At least half of them need someone’s help with
daily, life-sustaining activities.

What makes my life worth living? Being able to peck out
my thoughts on my Mac. Being able to share my thoughts with others who, I hope,
will appreciate them. Being able to reach out to friends. To be of some small
service to others who find themselves “in the same boat.” And maybe most
important, not be too alarmed by death or its not so clandestine approach. As
someone put it, “Nobody is really in charge except the marketplace.” And we
wait for the bio-ethicists to have some impact on the opposite of over-kill.
Maybe “over save-gate?” When does a life cease to be a life, and become a
prolonged and agonizing dying? Sick enough to never get better? When indeed?

Prostate cancer and I have been working allies
for almost a quarter of a century. Working my way through the thickets of fear
and health concerns, having a black belt prostate oncologist, Dr. Mark Scholz
as my guide, has left me far more conscious of health maintenance and wise
options. I have to confess I am in some ways a healthier and happier man from
living all these years with my cancerous prostate.

Tuesday, January 14, 2014

BY MARK SCHOLZ, MDHistorically,
prostate imaging with CT, ultrasound or MRI has been too inaccurate for diagnosing
prostate cancer.Random needle biopsy has been the mainstay of accurate
diagnosis. However, after a number of false starts, advances have brought
multiparametric MRI (MP-MRI) into the winner’s circle, even surpassing the
accuracy of random biopsy.Prostate Imaging Presents a Special
Challenge

Success
with prostate imaging has been a long time coming. While mammography for breast
imaging and CAT scans for lung cancer have enjoyed mainstream use for decades,
the technology to differentiate the high-grade prostate cancers from harmless,
low-grade prostate cancers—those that experts believe are better off being left
undiagnosed—has only been developed recently.

New Technology Brings Growing Pains

You
might think that new technological advances would immediately revolutionize
prostate cancer management. Not necessarily. Many doctors simply don’t know
what’s now available. Those that are aware are often unacquainted with the full
extent of its capabilities. And finally, even the fully informed doctors may be
reluctant to venture outside their comfort zone and embrace MP-MRI as a
substitute for doing a random biopsy.

Barriers to Change—The Status Quo has
Deep Roots

Random biopsy has been the de facto standard for 25 years.Prior to MP-MRI, biopsy was the ONLY way to
confirm the diagnosis of prostate cancer and obtain accurate information about
its extent. Additionally, periodic random biopsy has been fundamental to the
monitoring process in men with low-grade prostate cancer on Active Surveillance.
Biopsy has grown to become a very big business, performed in more than a
million men annually.It is financially
lucrative, paying thousands of dollars to providers for each procedure.

Ending the Twenty-five Year Reign of
Random Biopsy

Random
biopsy has major drawbacks. It misses high-grade cancer 15% of the time and 3%
of men end up in the hospital with uncontrolled infections.Repeat biopsies, such as those done to men on
active surveillance are uncomfortable, affect erectile function and incur an
even higher risk of infection. Most importantly, random biopsy over-diagnoses 100,000 men annually,
leading to rampant and excessive use of surgery or radiation.

Imaging with Multiparametric MRI

MP-MRI detects high-grade disease accurately and, thankfully, overlookslow grade disease,
thus sparing the shock of an unnecessary cancer diagnosis and, in many cases,
unwarranted treatment. Any suspicious lesions that are detected can be further investigated
with a targeted biopsy, a more
accurate way to find high-grade disease that requires far fewer biopsy cores. Men with a clear scan can usually forgo biopsy
altogether.The word “Multi-parametric”
means the performance of three scans sequentially during a single visit to the
imaging center:

1)T2-weighted
imaging allows for
the best assessment of the prostate morphology, size, margins and internal
structures with easy differentiation between the central and peripheral zones.

2)Diffusion-weighted imaging details the
tissue microstructure and generates an “apparent diffusion coefficient” (ADC)
which helps to determine the aggressiveness of a lesion if one is seen.

The
radiologist who reads the scans unifies the information from all three modalities
to compile a report. Findings are then summarized in an overall impression which falls into one of three categories:

First: No evidence for high grade disease,
no need for biopsy

Second: A suspicious lesion is detected, a targeted biopsy is probably necessary

Third: An ambiguous area is detected. Either
a targeted biopsy can be considered
or alternatively, ongoing monitoring with another scan in 6-12 months can be
considered

Scanning in the Context of Prostate
Size, PSA and Age

Men’s
prostates come in many sizes and shapes.MP-MRI accurately measures prostate size, which is essential to
interpreting PSA because an enlarged prostate produces higher PSA levels. An
oversized gland, therefore, provides a reassuringly benign explanation for a
modestly elevated PSA. Since many forms of prostate cancer take decades to grow
large enough to present a problem, a man’s age is also relevant to the
interpretation process. For example, elderly men with rather small ambiguous
lesions (Third) might be advised to follow up with further scans to determine
if it grows rather than going to a biopsy right away.

Scanning at a Center of Excellence

Very
few imaging centers can do prostate imaging at the level of quality we are
discussing. There are essentially three components required to achieve reliable
results: State-of-the-art, three-Tesla hardware; technicians who are precisely
trained in how to perform prostate imaging; and physicians carefully trained
specifically in the interpretation of prostate imaging. Imaging technology is
developing so rapidly that even some board-certified radiologists remain
unaware of what the latest technology can achieve.

Don’t Be Cheated Out of the Best
Technology

Today’s
MP-MRI scans, when performed at centers of excellence, generate prostate images
of stunning clarity. Every effort must be made to raise general awareness among
patients and doctors alike about the advantages of MP-MRI over random biopsy in
men with high PSA levels and in men who have been diagnosed with low-grade
cancer that are pursuing Active Surveillance.

Tuesday, January 7, 2014

Sometimes stress leaves a path as
distinct as a hurricane. Its onset can usually be tracked from the moment
cancer is diagnosed.If someone asked you if you were
feeling stressed, and if so, what were the symptoms, how would you describe
your condition? Signs of stress vary, and may be cognitive, emotional,
physical, or behavioral. And often the symptoms overlap.If we start with “cognitive” symptoms,
we encounter difficulty concentrating, a negative approach to simple matters,
anxious thoughts, excessive worrying, and unusual memory lapses. When I
was first diagnosed, I felt as if I was in a stupor. A daze. I lived in fear
that my impaired memory and brain function would be noticed by the people I was
working with. I was sensitive to loud noises. As one guy I know put it: “I
couldn’t exercise at my gym because they had 8 TVs playing different stations
and music piped through the entire exercise floor. The amount of information
overload was more than my brain could handle. Too much sound and light made me
feel both angry and anxious.”Emotional symptoms are fairly obvious:
Moodiness, and irritability, short temper, inability to relax, feeling
overwhelmed and depressed. Some people have a sense of loneliness and isolation.
Others feel a frightening loss of control. My stress made me feel paranoid. I
took things personally that had nothing to do with me. I found myself overly
sensitive to the criticism of other people.If someone didn’t respond to a text or
call me back immediately, I assumed they didn’t want to interact with me and
didn’t want to be my friend. If someone didn’t smile or say “Hi” as I walked by
I took it personally and began to analyze what I did wrong. I kept all my
friends at arm’s length because of an inordinate fear of being rejected or not
included.Physical symptoms from stress are also
very common. Theyvary from person to person and run the whole range:

Aches and pains

Diarrhea or constipation

Chest pain, rapid heartbeat

Frequent colds

Indigestion\

Loss of sex drive (whatever was left of it)

Low blood sugar

Nausea, dizziness

Behavioral symptomspresent in a variety
of ways, again depending on personality type. They would include irregular
eating habits and sleep habits, neglecting responsibilities, isolating oneself.
You can probably come up with other aspects of the “hurricane.” Just know that
you are not going crazy, that the symptoms you are experiencing are normal for
anyone after a diagnosis of prostate cancer, and that with proper counseling
stress can be eased. Whether you choose to attend a Support Group, work with a
therapist, find solace with prayer and meditation, or try Relaxation Therapy,
it is important to do something to master your stress so that you can
continue to manage your everyday life as well as make the right decisions to
fight the cancer.

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PROSTATE SNATCHER VIDEOS

MARK SCHOLZ, MD

Mark Scholz, MD is board certified in medical oncology and internal medicine. He has been treating men with prostate cancer exclusively since 1995. He is the Medical Director of Prostate Oncology Specialists, Inc., and Executive Director of the Prostate Cancer Research Institute. He is an acknowledged expert on management and treatment for prostate cancer using hormone intervention, immunotherapy, chemotherapy and angiogenesis as well as vitamin, herbal and other forms of lifestyle counseling. His affiliations include St. John's Health Center, Marina del Rey Hospital and others. Dr. Scholz also served as an associate clinical professor in the department of Oncology at USC School of Medicine. Dr. Scholz volunteers for the Internet list “Patient to Physician,” found via Resources at www.pcri.org . You may also find current posts on twitter. www.twitter.com/markscholzmd

RALPH H. BLUM

Ralph H. Blum is a cultural anthropologist and author, graduated Phi Beta Kappa from Harvard University with a degree in Russian Studies. His reporting from the Soviet Union, the first of its kind for The New Yorker (1961—1965), included two three-part series on Russian cultural life. He has written for various magazines, among them Reader’s Digest, Cosmopolitan, and Vogue. Blum has published three novels and five nonfiction books. He has been living with prostate cancer, without radical intervention, for twenty years.

PROSTATE ONCOLOGY SPECIALISTS

Established in 1995, Prostate Oncology Specialists has earned national acclaim for its comprehensive approach to prostate cancer prevention and management. Under the direction of Medical Director Mark Scholz, M.D., Prostate Oncology Specialists employs a highly skilled team of physicians trained in oncology, radiology, hematology, and internal medicine who treat all stages of prostate cancer. Prostate Oncology Specialists are not wedded to any single therapy for prostate cancer, but rather advocate the exploration of treatment options that are customized and tailored to the unique needs of each individual patient. Treatments employed include active surveillance, testosterone deprivation, partial cryotherapy, seed implantation, intensity-modulated radiation, and surgery. Prostate Oncology Specialists’ ongoing mission is to uncover new medical breakthroughs in the treatment and management of prostate cancer.

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